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RC1 83  .N44  Variola  and  vaccinia 


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EDWARD   JENNER,    M.  D.,    LL.  D.,    F.  R.  S.,   &c. 


VARIOLA 


AND 


VACCINIA. 


History  and  Description. 


Hints  Relating  to  the  Propagation  of  Vaccine  Virus. 

Certain  Anomalies  in  the  Course  of  the 

Vaccine  Disease. 


WITH  ILLUSTRATIONS. 


ISSUED    BV 

THE  NEW   ENGLAND   VACCINE   COMPANY, 

294  Broadway,  Chelsea  Station, 

boston,  mass. 

wm.  c.  cutler,  m.  d.  j.  f.  frisbie,  m.  d. 

copyrighted. 


//Vf 


VARIOLA. 

NO  definite  knowledge  of  the  origin  of  the  destructive 
plague,  small-pox,  has  been  discovered  bv  writers 
on  the  subject,  but  histories  and  traditions  of  East- 
ern nations,  especiall}^  of  China  and  Hindostan,  refer  its 
commencement  to  a  remote  period  before  the  Christian  era. 
]\Iost  authorities  place  the  date  of  its  appearance  in  Egypt 
about  A.  D.  544,  although  it  is  believed  by  some  writers 
that  Philo,  a  Jewish  philosopher,  mentioned  it  in  a  work 
on  the  Ivife  of  IMoses,  written  in  the  first  centurv.  It 
spread  into  x'Ysia  and  Africa  during  the  sixth  and  seventli 
centuries,  and  into  the  countries  of  Europe  in  the  ninth 
and  tenth  centuries.  The  Spaniards  carried  it  into  Cuba 
and  San  Domingo  soon  after  the  discover}^  of  America. 
It  raged  in  Mexico  in  1527,  its  victims  numbering  millions. 
From  that  date  it  graduall}-  extended  over  the  whole 
American  continent. 

The  first  accurate  and  scientific  description  of  the 
disease  came  from  Rhazes,  a  celebrated  Arabian  phj^sician, 
A.  D.  925-926.  Records  of  historians  and  travellers  from 
the  earliest  ages  teem  with  dismal  details  of  the  destruc- 
tion of  human  life  bj-  this  contagion.  Its  aAvful  visitations 
seem  to  have  been  common  throughout  the  world. 

The  annual  mortality  from  small-pox  in  England  is 
said  to  have  averaged  about  three  thousand  to  each  million 
of  inhabitants. 

In  France  thirty  thousand  victims  perished  each  year. 

In  the  Russian  Empire  it  is  reported  to  have  been  so 
malignant  as  to  have  cut  off  two  millions  of  inhabitants  in 
a  single  year. 


During  the  years  from  1783  to  1799,  inclusive,  one- 
tenth  of  the  entire  death-rate  of  Berlin  was  from  this 
disease  alone. 

Dr.  Lettsom,  of  London,  calculated  that  in  Europe, 
annually,  two  hundred  and  ten  thousand  beings  were  by 
this  means  deprived  of  life. 

In  Ceylon  its  appearance  caused  whole  villages  to  be 
abandoned. 

More  than  one  hundred  thousand  Indians  were 
destroyed  by  it  in  one  year  in  the  province  of  Quito, 
South  America. 

It  was  no  respecter  of  persons.  Kingdoms  and 
empires  were  thrown  into  confusion  by  the  death  of 
crowned  heads.  Among  its  royal  victims  history  mentions 
five  descendants  of  Charles  I.,  of  Great  Britain,  viz. : 
Henr}^,  Duke  of  Gloucester;  Mary,  wife  of  the  Prince  of 
Orange  and  mother  of  William  III. ;  Charles,  Duke  of 
Cambridge,  in  1677  ;  Mary,  Queen  of  England  and  wife  of 
William  III.,  in  1694;  and  the  Princess  Mary  Louisa  in 
1712.  Also  five  descendants  of  Louis  XIV.,  of  France, 
and  in  the  same  period  Joseph  I.,  Emperor  of  Germany, 
in  1711;  Peter  II.,  Emperor  of  Russia,  in  1730;  a  queen 
of  Sweden  in  1741  ;  Henry,  Prince  of  Prussia,  1767; 
Maximilian  Joseph,  Elector  of  Bavaria,  in  1777. 

Macaula}^,  the  English  historian,  did  not  exaggerate 
when  he  called  the  disease  "the  most  terrible  of  all  the 
ministers  of  death,"  and  said,  in  describing  its  ravages  in 
the  seventeenth  century,  "Small-pox  was  alwaj^s  present, 
filling  the  churchyard  with  corpses,  leaving  on  those 
whose  lives  it  spared  the  hideous  traces  of  its  power,"  for 
two-thirds  of  the  pauper  blind  in  England  were  made  so 
by  this  cause. 


Dr.  Cyrus  Hdson,  Chief  Inspector  of  Contagious 
Diseases,  New  York  Health  Department,  in  his  Annual 
Report  of  1S90,  saj's:  "Small-pox  is  fatal  to  a  very  large 
proportion  of  those  whom  it  attacks.  It  kills  from  thirty 
to  forty  per  cent,  of  its  victims.  It  has  been  described 
with  great  accuracy  by  very  early  writers  ;  nevertheless, 
its  history  previous  to  the  seventeenth  centurj^  is  obscure, 
and  must  be  regarded  as  defective  on  account  of  its  having 
been  confounded  with  measles  and  other  forms  of  eruptive 
disease. 

"  During  the  seventeenth  and  eighteenth  centuries  not 
a  decade  passed  without  an  occurrence  of  fearful  epidemics 
of  small-pox.  In  England  from  seven  to  nine  per  cent,  of 
all  the  deaths  were  due  to  it.  It  was  one  of  the  most 
destructive  diseases,  attacking,  as  it  did,  persons  in  everjr 
station  in  life. 

"  During  the  sixteenth  century,  in  Alexico,  3,500,000 
persons  died  of  small-pox.  In  1734  nearly  two-thirds  of 
the  population  of  Greenland  were  swept  away  by  an 
epidemic  of  the  disease;  and  in  Iceland  18,000  persons 
died  out  of  a  population  of  50,000. 

"  Its  ravages  among  savage  nations  are  not  less  disas- 
trous than  among  the  civilized.  Whole  tribes  have  been 
exterminated.  Washington  Irving  and  other  writers  have 
graphically  described  the  horrors  it  wrought  among  our 
North  American  Indians. 

"  One  of  the  most  vivid  pen-pictures  of  the  devastation 
wrought  by  small-pox  before  the  introduction  of  vaccina- 
tion is  given  by  Professor  Wernher,  in  his  work  entitled 
'Zur  Impffrage.'     It  is  as  follows 

"  '  Before  the  introduction  of  vaccination  small-pox  had 
become  a  permanent  disease  Avhich  never  entirel}^  ceased 


in  any  one  year,  and  every  three  or  five  years  became  a 
great  epidemic. 

"  'In  non-epidemic  years  one-tenth  of  all  mortality  was 
from  variola  ;  in  epidemic  years,  one-half. 

"  '  Very  few  men  escaped  small-pox  till  old  age  ;  almost 
every  one  sickened  at  least  once  in  his  life  of  this  horrible, 
murderous  disease. 

" '  Countless  mortals  were  maimed  by  loss  of  sight. 
Of  new-born  children  one-third  died  of  small -pox 
before  their  first  year;  one-half  before  their  fifth  year 
of  life. 

" '  There  was  no  family  which  had  not  heavy  losses  to 
deplore. 

" '  In  the  country  the  mortality  was  greater  than  it  was 
in  the  city. 

"'Physicians  and  government  possessed  no  means 
against  this  abominable  evil.  Isolation  was  impracticable, 
from  the  wide-spread  nature  of  the  disease.  Men  accepted 
the  pest  as  an  unavoidable  fate. 

"  'The  loss  which  Europe  suffered  from  this  one  disease 
amounted  to  many  millions.  It  was  the  principal  factor 
which  deterred  or  kept  back  the  population  from  progress ; 
and  to  lead  us  back  to  these  conditions  are  the  efforts  of 
many  ignorant  mortals  directed.' 

"  Comparing  the  present  conditions  with  those  just 
stated,  the  author  goes  on  to  say: 

" '  We  now  find  no  child  mortality  among  vaccinated 
children.  Also  among  adults,  whenever  vaccination  and 
revaccination  are  maintained,  mortality  from  small-pox  is 
at  an  end,' 

"The  following  table  is  compiled  from  the  'Report  of 
the    Epidemological    Society  of   London,'   and    shows    the 


mortality  from  small-pox  during  periods  before  and  after 
the  introduction  of  vaccination.  The  periods  are  not  in 
each  case  the  same,  but  they  are  those  of  which  it  was 
possible  to  obtain  reliable  information. 

APPROXIMATE  AVERAGE  ANNUAL  DEATH-RATE  BY  SMALL-POX 

PER  MILLION. 


Period  Rei^ative  to 
WHICH  Data  are  Given. 

Country  or  City. 

Before 
Vaccina- 
tion. 

After 
Vaccina- 
tion. 

1777-1806  and  1807-1850. 

Lower  Austria, 

2,484 

340 

1776-1780  and  1810-1850. 

Prussia,  Eastern, 

3.321 

56 

1780  and  1810-1850. 

Prussia,  Western, 

2,272 

356. 

1781-1805  and  1810-1850. 

Berlin, 

3,422 

176 

1774-1801  and  1810-1850. 

Sweden, 

2,050 

15S 

"In  the  table,  of  which  the  foregoing  is  a  part,  twenty-one 
other  cities  or  States  are  given,  each  of  which  shows  the 
same  remarkable  reduction.  I  would  call  your  attention 
particularly  to  Berlin.  The  death-rate  from  small-pox 
there  was  3,422  per  million  living  inhabitants  during  the 
twenty-four  years  before  the  introduction  of  vaccination, 
and  176  per  million  in  the  forty  years  after  that  time. 

"  In  the  city  of  New  York  the  following  table,  compiled 
from  the  yearly  records  of  the  Health  Department,  shows 
the  death-rate  from  small-pox  from  1869  to  1888,  inclusive: 


DEATHS  FROM  SMALL-POX. 


Year. 

DUATHS. 

Population. 

Ratjj  per 

100,000. 

Year. 

Deaths. 

Population. 

Rate  Per. 
100,000. 

1869 

203 

927,728 

21.90 

18S0 

31 

1,206,299 

2.57 

1870 

805 

942,292 

31.08 

1881 

453 

1,242,533 

33-30 

1871 

805 

954,636 

84.32 

1882 

259 

1,279,560 

20.34 

1872 

929 

967,142 

96.16 

1   1883 

12 

1,317,691 

0.91 

1873 

117 

979,811 

11.94 

i   1884 

0 

1,356,958 

0.00 

1874 

484 

992,646 

48.75 

1885 

26 

1,397,395 

1.86 

1875 

1,280 

1,041,886 

122.85 

1886 

31 

1,439,037 

2.15 

1876 

315 

1,072,934 

29.36 

1   1887 

99 

1,481,920 

6.68 

1877 

14 

1,104,907 

1.27 

1888 

81 

1,526,081 

5-31 

1878 

2 

1,137,833 

0.18 

;  1889 

I 

1879 

25 

1,171,740 

2.13 

1890 

0 

"The  results  of  the  work  of  the  Vaccination  Corps  did 
not  become  apparent  until  1876. 

"The  death-rate  from  small-pox  previous  to  1876  was 
59.57  per  100,000.  Since  that  year  it  has  been  only  8.38 
per  100,000. 

"In  Paris,  where  vaccination  is  not  energetically  en- 
forced, the  death-rate  from  small-pox  ranges  from  136  to 
10. 1  per  100,000  inhabitants. 

"In  the  principal  German  cities,  where  vaccination  laws 
are  enforced  with  rigor,  the  death-rate  from  small-pox  is 
1.44  per  100,000  inhabitants. 

"In  London,  where  compulsory  vaccination  is  rigidly 
enforced,  the  death-rate  from  small-pox  is  only  0.6  per 
100,000. 

"  In  the  Canton  of  Zurich,  Switzerland,  since  the  com- 
pulsory vaccination  law  was  repealed,  the  mortality  from 
small-pox  has  risen  from  8  to  85  per  100,000  inhabitants. 

"When  small-pox  prevails  in  a  community  where  some 


are  protected  by  vaccination  and  others  are  not,  the  in- 
fluence of  vaccination  is  strikingl}'  exhibited. 

"In  observations  shown  for  twenty-one  A^ears  on  4,000,000 
people  in  Bohemia,  it  was  discovered  that  the  death-rate 
among  vaccinated  persons,  in  whom  the  protected  power 
had  diminished  b}^  reason  of  age,  was  5  1-16  per  cent., 
while  among  those  who  had  never  been  vaccinated  it  was 
29  4-5  per  cent.  Illustrations  of  this  kind  could  be  multi- 
plied, as  almost  countless  authentic  statistics  exist. 

"In  New  York  the  first  question  asked  by  the  Inspector 
of  Contagious  Diseases  of  a  person  sick  with  a  doubtful 
case  of  small-pox  is,  'When  were  you  successfully  vaccin- 
ated ?  '  And  if  the  answer  indicates  it  was  done  a  period 
of  five  or  six  years  before,  the  disease  is  believed  not  to 
be  small-pox. 

"During  over  nine  3'ears  of  service  in  the  Health  Depart- 
ment of  New  York  I  have  never  seen  a  case  of  small-pox 
in  a  person  who  had  been  vaccinated  successfully'  within 
five  years,  and  the  number  of  cases  I  have  seen  mount 
into  hundreds. 

"During  that  period,  I  have  seen  only  one  Inspector  of 
Contagious  Diseases  contract  small-pox,  and  he  was  the 
only  Inspector  who  disbelieved  in  vaccination,  and  refused 
to  have  it  performed  on  himself." 

INOCULATED   VARIOLA. 

From  a  very  early  period  in  the  history  of  small-pox, 
inoculation  had  been  extensively  performed  in  Eastern 
countries,  particularly  in  China,  India  and  Turkey,  and 
in  1722  the  practice  was  adopted  in  England  and  America. 

To  mitigate  the  loss  of  life  and  contagious  effects  of  a 


disease  so  generally  feared  because  of  its  malignity,  many 
individuals,  in  the  hope  of  gaining  securit}'  against  future 
attacks,  submitted  to  inoculation,  which  produced  the 
malady  in  a  less  severe  form. 

The  virus  from  small-pox  was  introduced  into  the 
circulation  through  the  skin,  this  process  resulting  in  a 
comparatively  mild  form  of  the  disease.  It  proved  to  be  a 
benefit  to  those  inoculated,  but  a  constant  source  of  conta- 
gion was  established.  Small-pox  propagated  in  this 
manner  convej^ed  infection  to  such  an  extent  that  the 
general  mortality  was  greater  than  before  the  practice 
was  known. 

In  1840  an  Act  of  Parliament  was  passed,  rendering 
small-pox  inoculation  unlawful  in  England. 

In  many  of  the  older  towns  in  New  England,  the  ruins 
of  hospitals,  for  the  isolation  and  inoculation  of  small-pox 
can  be  seen  to-day. 

MEASLES. 

Among  the  eruptive  diseases  most  similar  in  their 
early  stages  to  variola,  the  correct  differential  diagnosis  of 
which  has  often  puzzled  men  of  experience,  may  be 
mentioned  measles,  varicella,  and,  in  rare  cases,  the 
papular  form  of  secondarj^  sj^philis.  This  last,  however, 
is  of  so  infrequent  appearance  and  is  attended  with  so 
slight  general  fever  that  little  need  be  said  of  it. 

In  measles,  each  erythematous  patch  will  be  found  to 
cover  a  larger  area  than  variola.  A  case  of  variola  with 
erythema  as  extensive  as  is  seen  in  measles  would  be 
attended  with  a  temperature  as  high  as  104  or  105,  with 
pulse  correspondingly  high,  while  in  measles  the  tempera- 


II 


ture  seldom  rises  above  loi  or  102.  In  measles  the 
catarrhal  symptoms,  sneezing,  increased  lachrymal  secre- 
tions, suffused  conjunctivse,  and  an  obstinate  cough, 
precede  the  eruption,  or  appear  at  the  same  time.  So 
important  a  symptom  is  the  cough,  that  it  is  often  said 
that  an  eruption  having  the  appearance  of  measles  should 
not  be  diagnosed  as  that  disease  if  the  cough  is  not 
present.  In  variola  this  symptom  is  usually  absent,  or 
may  appear  at  a  later  stage  of  the  disease.  In  measles 
the  eruption  pales  and  begins  to  fade  on  the  second  or 
third  day.  In  variola  it  becomes  intensified,  with  a  slowly 
forming  vesicle  in  its  centre. 

VARIOLA   AND   VARICELLA. 

The  following  extract  from  the  writings  of  Dr.  John  D. 
Fisher,  of  Boston,  gives  an  admirable  comparative  descrip- 
tion of  the  two  diseases. 

"In  most  cases  the  chicken-pox  is,  by  the  experienced 
observer,  easily  and  readily  distinguished  from  the  small- 
pox. When,  however,  the  former  is  extraordinarily  violent, 
and  the  latter  unusually  mild,  the  distinguishing  marks 
are  obscure,  and  the  two  diseases  are  therefore  frequent!}- 
confounded.  To  render  the  distinctions  as  clear  as  possible, 
the  more  prominent  symptoms  of  the  two  diseases  are  here 
contrasted  with  each  other. 

"  In  small-pox  the  fever  is  ushered  in  hy  a  cold  stage,  is 
severe  and  continues  three  or  four  days,  and  if  it  declines 
or  ceases  during  the  eruptive  process,  it  commonlv  reap- 
pears during  the  suppurative  stage,  or  between  the  fifth 
and  eighth  day  of  the  eruption. 

"  In  chicken-pox  the  fever  is  not  often  preceded  by  a  cold 


VARICELLA. 
Third  Day  of  the  Eruption. 


^ 


VARIOLA. 
Third  Day  of  the  Eruption. 


14 

Stage,  is  uniformly  light  and  is  frequently  insensible;  it 
seldom  continues  more  than  two  days  and  never  reappears 
after  it  has  once  ceased.  When,  however,  the  vesicles 
appear  in  successive  crops  the  fever  lasts  longer  and  rages 
until  the  eruption  is  completed. 

"In  small-pox  the  eruption  is  often  preceded  or  accom- 
panied by  an  erysipelatous  efflorescence. 

"  In  chicken-pox  this  efflorescence  does  not  take  place. 

"In  small-pox  the  eruption  does  not  break  out  until  the 
third  or  fourth  day  of  the  fever;  it  appears  first  on  the 
face,  then  on  the  neck,  chest,  trunk  and  extremities,  and 
is  completed  in  the  course  of  two  days. 

"  In  chicken-pox  the  eruption  breaks  out  by  the  termi- 
nation of  the  first  or  on  the  second,  and  almost  invariably 
before  the  end  of  the  third  day  of  the  fever;  it  usually 
appears  first  about  the  breast  and  shoulders,  afterwards 
on  the  face  and  extremities.  It  often,  however,  follows  a 
different  order,  and  is  never  so  uniform  in  the  method  of 
its  invasion  as  the  eruption  of  the  small-pox ;  it  frequently 
appears  in  successive  crops  for  four  or  five  days. 

"In  small-pox  the  eruption  presents  itself  in  the  form 
of  small  red  circular  points  or  papulae;  these  are  hard, 
resisting  and  movable,  and  communicate  to  the  finger  a 
shot-like  sensation.  They  scarcely  project  above  the 
surface,  but  are  easily  and  distinctly  felt  by  drawing  the 
finger  over  them. 

"In  chicken-pox  the  eruption  likewise  breaks  out  in 
small  inflamed  spots,  but  these  are  not  papular  in  their 
origin,  and  are  not  exactly  circular,  but  tend  to  an  oblong 
figure.  They  may  be  distinctly  felt  by  the  finger,  but 
they  are  yielding  under  it  and  are  destitute  of  the  tuber- 


VARIOLA. 
Fourth  Day  of  the  Eruption. 


i6 

cular  hardness  and  rolling  motion  which  characterize  the 
variolous  eruption  at  the  same  period, 

"In  small-pox  the  eruption  seldom  becomes  vesicular 
before  the  end  of  the  second  or  the  commencement  of  the 
third  day,  and  the  vesicles  are  confined  to  the  summits  of 
the  pocks. 

"In  chicken-pox  the  eruption  is  vesicular  from  the 
beginning,  or  from  the  early  part  of  the  first  day,  and 
by  the  second  day  the  whole  surface  of  the  pocks  are 
converted  into  vesicles  which  resemble  little  bladders  of 
transparent  fluid. 

"In  siiiall-pox  the  pustules  at  first  have  acuminated 
summits;  they  afterwards  become  rounded,  and  at  an 
early  period  present  slight  depressions  in  the  centre  of 
their  surfaces. 

"In  chicken-pox  the  vesicles  are  usually  lenticular  in 
form,  but  are  sometimes  conoidal  or  globate,  and  preserve 
one  shape  through  their  course,  or  until  they  become 
ruptured. 

"  In  small-pox  the  eruption  is  situated  in  the  substance 
of  the  cutis,  as  has  been  proved  by  dissection,  and  as  is 
evident  from  the  sensation  which  the  pustules  communi- 
cate to  the  finger. 

"In  chicken-pox  the  vesicles  are  not  formed  in  the 
true  skin,  but  are  situated  upon  its  surface  in  the  cellular 
tissue  between  the  skin  and  cutis. 

"In  small-pox  the  pustules  after  they  have  become 
vesicular  are  distinguished  by  hard,  unyielding  bases. 

"In  chicken-pox  the  vesicles  are  destitute  of  such 
tubercular  bases.  The}^  are  yielding  and  easil}^  give  way 
under  pressure,  and  communicate  to  the  finger  a  soft, 
elastic    sensation,  or    a    feeling    similar   to    that   which    a 


1^ 

ir 


i 


VARIOLA. 
Fifth  Day  of  the  Eruption. 


minute  globule  of  fine  sponge  softened  with  water  would 
give  rise  to  when  pressed. 

"  In  small-pox  the  pustules  are  composed  of  little  cells, 
all  of  which,  however,  communicate  with  each  other;  and 
the  cuticular  coverings  of  the  pocks  are  opaque,  tough  and 
not  easily  broken. 

"In  chicken-pox  the  vesicles  are  composed  of  a  single 
cavity,  and  the  coverings  are  extremely  thin  and  fragile, 
are  diaphanous  and  are  very  easily  broken. 

"In  sniall-pox  the  pustules  are,  at  an  early  stage, 
filled  with  a  serous  secretion ;  this  after  a  time  becomes 
converted  into  a  purulent  matter  that  exhales  a  very 
unpleasant  and  peculiar  odor. 

"In  chickenpox  the  vesicles  contain,  when  fully 
matured,  only  a  whitish,  transparent  and  serous  fluid ; 
this  never,  except  through  accident,  becomes  pus,  and  is 
destitute  of  any  ungrateful  odor. 

"  In  smallpox  the  pustules  remain  whole  till  they 
are  six  or  seven  days  old,  when  some  of  them  commonly 
become  ruptured,  and  permit  a  little  of  the  virus  to  ooze 
out  upon  their  surface;  but  they  still  retain  their  form 
and  prominency. 

"  In  chickenpox  the  vesicles  often  become  broken  in 
two  or  three  days  after  their  appearance,  and  permit  the 
whole  of  their  contents  to  escape.  Their  coverings  then 
sink  down  and  collapse,  and  the  vesicles  become  flattened 
and  lose  their  original  form.         ■ 

"In  s7nall-pox  the  pustules .  break  out  simultaneously, 
pursue  a  regular  march  and  arrive  at  maturity  at  about 
the   same  time. 

"  In  chicken-pox  the  vesicles  generally  break  out  in 
successive  crops   for  a  number  of  days,  in  which   case  a 


VARIOLA. 
Sixth  Day  of  the  Eruption. 


20 


great  variety  may  be  observed  among  them;  some  are 
appearing,  whilst  others  are  fully  formed,  shrivelled  or 
crusted. 

"  In  small-pox  desiccation  does  not  commence  till  about 
the  eighth  day  from  the  appearance  of  the  eruption. 

"  In  chicken-pox  when  the  vesicles  run  their  course 
without  bursting,  desiccation  commences  in  them  as  early 
as  the  fifth  day  of  their  age,  but  it  always  begins  as  soon 
as  the  vesicles  are  ruptured,  and  consequently  it  more 
usually  commences  on  the  third  or  fourth  day,  and  some- 
times as  early  as  the  second  day  after  they  appear. 

"  In  small-pox  the  processes  of  eruption,  of  suppuration 
and  of  desiccation  constitute  three  successive  periods, 
rendered  distinct  from  each  other  by  their  duration;  the 
first  occupies  about  three  days  and  the  other  two  about 
five  days  each. 

"In  chicken-pox  these  three  periods  seem  to  be 
confounded  in  consequence  of  the  pocks  appearing  in 
successive  crops,  and  even  when  they  are  distinguishable, 
the  sum  of  their  duration  seldom  exceeds  eight  days. 

"  In  small-pox  the  scabs  fall  off  in  a  single  piece. 

"In  chicken-pox  the  scabs  do  not  usually  fall  off  in  a 
single  piece,  but  in  small  fragments  of  different  forms  and 
sizes. 

"The  small-pox  even  when  distinct  and  of  moderate 
mildness,  is  a  disease  of  fifteen  or  twenty  days  in  duration, 
and  it  often  proves  fatal. 

"The  chicken-pox^  on  the  contrary,  runs  its  course  and 
is  completed  in  five  or  six  days,  or  in  eight  or  ten  at  most, 
and  it  never,  of  itself,  proves  fatal. 

"The  distinctions  between  the  chicken-pox  and  the 
varioloid  disease,  or  the  small-pox  in  its  modified  form,  are 


VARIOLA. 
Seventh  Day  of  the  Eruption. 


less  striking,  and  less  easily  recognized.  The  following 
peculiarities,  however,  may  generally  be  observed  in  the 
two  diseases,  and  will,  in  most  cases,  lead  to  a  correct 
discrimination. 

"The  chicken-pox^  as  has  already  been  stated,  is 
distinguished  by  the  eruptive  fever  being  generally  light. 

"In  the  varioloid  disease  the  precursory  fever  is  com- 
monly sharp  and  of  several  da3's'  duration. 

"In  chicken-pox  the  eruption  appears  in  the  form  of 
vesicles,  or  it  is  vesicular,  at  least,  from  an  early  period 
of  the  first  da3^ 

"In  the  varioloid  disease  the  eruption  is  always  papular 
in  its  origin,  and  seldom  becomes  vesicular  before  the 
second  or  third  day.  It  appears  all  at  once  and  seldom 
breaks  out  in  successive  crops.  The  pocks  are,  in  the  first 
instance,  elevated  on  solid  tubercular  bases,  and  their  tops 
are  resisting  and  not  easil}^  broken.  The  eruption,  as  in 
the  unmodified  variola,  is  formed  in  the  substance  of  the 
true  skin,  as  is  evident  from  the  hard  and  elevated  bases 
which  remain  after  the  lymph  is  removed  from  the  pustules 
by  puncture  and  pressure,  and  by  the  kernels  or  tubercular 
elevations  which  remain  in  the  skin  after  the  scabs  have 
fallen  off.  The  pocks  from  their  first  formation  are  hard 
and  unyielding,  and  are  movable  and  rolling  under  the 
finger. 

"To  these  distinguishing  characteristics,  all  of  which 
have  been  noticed  by  various  writers,  the  author  would  add 
the  following: 

"In  chicken-pox^  if,  during  the  first  day  of  the  eruption, 
the  parts  on  which  it  exists  be  embraced  with  the  thumb 
and  finger  and  gently  distended  by  them;  or  if  a  single 
finger  be  drawn  over  them  with  a  force  just  suf&cient  to 


VARIOLA. 
Eighth  Day  of  the  Eruption. 


24 

cause  the  little  rugae  of  tlie  cuticle  to  become  smootli,  the 
inflamed  spots,  in  which  form  the  vesicles  first  present 
themselves,  readily  disappear  and  leave  no  discoloration  or 
induration  in  the  skin. 

"In  the  varioloid  disease^  if  a  like  distention  of  the 
parts  occupied  by  the  eruption  be  made  at  the  same  date, 
the  inflamed  spots  disappear  less  readily  and,  even  when 
the  distending  force  is  sufficiently  great  to  make  them 
disappear,  a  dim  discoloration  can  be  perceived  and  a 
distinct  shot-like  hardness  may  be  felt  at  the  points  upon 
which  they  were  planted. 

"In  chicken-pox  the  scars  left  in  the  skin  after  desqua- 
mation are  destitute  of  any  peculiar  hardness,  and  are,  in 
the  space  of  a  few  days,  entirely  erased. 

"  In  the  varioloid  disease  the  eruption,  for  a  considerable 
time  after  the  scabs  have  fallen,  leaves  little  kernels,  or 
tubercular  elevations,  in  the  skin.  The  varioloid  disease 
has  the  power  of  communicating  the  unmodified  and 
modified  small-pox." 

In  addition  to  a  careful  study  of  these  distinguishing 
features,  the  physician  should  as'^ertain  if  the  patient  has 
been  successfully  vaccinated  within  five  years;  if  so,  the 
probability  is  in  favor  of  varicella,  particularly  if  the 
subject  is  a  child,  as  varicella  rarely  affects  an  adult. 

As  an  aid  to  the  physician  in  making  his  diagnosis  of 
variola,  the  photographs  shown  may  be  valuable,  as 
they  are  the  only  known  photographs  of  this  disease  in 
existence. 


VARIOLA. 
Tenth  Day  of  the  Eruption. 


J 


VARIOLA. 
Eleventh  Day  of  the  Eruption. 


VARIOLA. 
Eleventh  Day  of  the  Eruption. 

Actual  size  of  the  pustules. 


28 


VACCINIA, 

In  1798,  Edward  Jenner,  M.  D.,  F.  R.  S.,  a  surgical 
practitioner  of  Berkeley,  Gloucestershire,  England,  in  a 
pamphlet  entitled  "xVn  Inquiry  into  the  Causes  and  Effects 
of  the  Variolas  Vaccina,"  made  known  to  the  world  the 
discoveries,  investigations  and  experiments  which  he  had 
heen  conducting  for  twenty  j^ears,  in  the  hope  of  proving 
theories  the  successful  practice  of  which  would  secure 
immunit}^  from  this  pestilence  without  endangering  life. 
He  had  observed  that  the  dair^-  folk  in  that  section  of  the 
countr}^  were  generallj^  exempt  from  small-pcx,  and,  from 
the  casual  remarks  of  a  milker,  had  learned  that  this  was 
supposed  to  be  due  to  the  fact  that  man}'  of  them  had 
accidentally  contracted  cow-pox  from  "sores  en  the  cows' 
teats,''  and,  in  this  wa}-,  became  insusceptible  to  the 
contagion  of  small-pox.  Experiments  proved  the  correct- 
ness of  this  theorj^,  for  in  two  3^ears  Jenner  inoculated 
over  six  thousand  subjects  with  the  virus  of  cow-pox,  and 
those  persons  were  afterward  exposed  to  small-pox  without 
■effect. 

Vaccinia,  or  cow-pox,  is  a  specific  eruptive  disease 
which  occurs  as  the  result  of  transmission  among  young 
cows  and  milch  heifers.  It  was  by  no  means  uncommon, 
and  after  attention  was  called  to  it  by  Jenner,  the  disease 
was  known  to  have  existed  in  at  least  eighteen  counties  in 
England.  There  are  recorded  discoveries  of  cow-pox  in 
the  cow  in  other  European  countries,  and  in  South 
America,  Asia  and  Russia.  In  1809  it  was  said  to  have 
been  observed  bj- ph^-sicians  in  Massachusetts  and  Connect- 
icut. In  many  cases,  stocks  wxre  raised  from  these  and 
passed  more  or  less  into  general  use,  but  in  America  the 
Jenncrian  stock  was  all  that  could  be  depended  upon. 


29 

Dr.  Samuel  A.  Green,  the  able  historian  of  the  Massa- 
chusetts Medical  Society,  in  his  centennial  address,  has 
given  the  following  valuable  information  in  regard  to  the 
early  history  of  vaccination  in  this  country.  "The  pro- 
tective power  of  vaccination  was  discovered  in  England  by 
Edward  Jenner,  near  the  end  of  the  last  century,  and  the 
news  of  its  discovery  was  soon  brought  to  this  country. 
Among  the  first  persons  here,  and  perhaps  the  first,  whose 
critical  attention  was  called  to  its  importance,  was  Dr. 
Benjamin  Waterhouse,  of  Cambridge,  an  early  Fellow  of 
this  Society.  Its  introduction,  like  that  of  variolous  inocu- 
lation, was  destined  to  meet  with  many  difficulties  and 
obstacles,  and  Dr.  Waterhouse  was  to  be  the  champion. 
He  wrote  much  as  an  advocate  of  the  cause,  and,  against 
popular  ridicule  and  prejudice,  he  succeeded  in  carrying 
the  day.  A  communication,  signed  with  his  initials  and 
dated  at  Cambridge,  March  12,  is  found  in  the  Columbian 
Ccntinel  oi  March  16,  1799.  It  is  headed,  'Something 
Curious  in  the  Medical  Line,'  and  is  the  first  account  of 
vaccination  that  was  given  to  the  public  in  this  country, 

"He  printed  the  account  in  a  newspaper  in  order  to 
excite  '  the  attention  of  our  dairy  farmers  to  such  a 
distemper  among  their  cows,'  and  to  inform  the  profession 
generally  of  this  security  against  small-pox.  Massachu- 
setts was  the  first  colou}^  to  introduce  small-pox  inoculation, 
and  she  was  also  the  first  State  to  adopt  kine-pox  vaccina- 
tion. During  the  summer  and  autumn  of  1802,  some 
interesting  experiments  were  conducted  under  the  direction 
of  the  Boston  Board  of  Health,  whose  unremitting  exertions 
at  that  time,  to  prevent  contagious  diseases,  entitle  them  to 
the  highest  praise.  The  Board  fitted  up  a  hospital  on 
Noddle's  Island,  now  known  as  East  Boston,  and  invited  a 


30 

number  of  physicians  to  co-operate  with  them  in  an  under- 
taking to  diffuse  knowledge  and  dispel  prejudice  in  regard 
to  vaccination. 

Some  bold  experiments  were  tried  at  this  hospital,  and 
fortunately  all  were  successful.  On  August  i6,  nineteen 
boys  were  vaccinated,  and  all  passed  through  the  regular 
stages  of  the  cow-pox;  and  on  November  9th,  twelve  of 
these  children,  together  with  the  son  of  Dr.  Bartlett,  who 
had  previously  had  the  cow-pox,  were  inoculated  for  the 
small-pox,  with  matter  taken  from  a  patient  in  the  most 
infectious  state  of  the  disease,  and  no  trouble  whatever 
followed.  They  had,  moreover,  been  exposed  to  infection, 
most  of  them  for  twenty  days,  by  being  in  the  same  room 
with  the  two  lads  who  had  the  small-pox;  and  all  nineteen 
escaped.  These  and  other  facts  are  given  in  a  report  which 
was  made  and  signed  by  eleven  physicians,  James  Lloyd 
and  Benjamin  Waterhouse  appearing  at  the  head  of  the 
list.  A  full  and  official  account  of  the  whole  affair  is  found 
in  the  Columbian  Centinel^  Dec.  18,  1802." 

Vaccination,  as  originally  practised  by  Jenner,  was 
performed  with  the  cow-pox  lymph  direct  from  the  animal 
on  a  few  selected  cases  only,  the  humanized  vaccine  virus 
so  produced  being  subsequently  transmitted  from  one 
person  to  another,  through  many  generations.  In  this 
arm-to-arm  vaccination,  the  lymph  probably  passed  through 
millions  of  human  systems,  and  very  naturally  the  efficacy 
decreased,  owing  to  its  continued  use  for  over  seventy 
years. 

The  marked  increase  in  mortality  from  small-pox  among 
the  vaccinated  seemed  to  indicate  that  repeated  human 
transmissions  had  so  deteriorated  the  old  Jennerian  stock 
as   to  render   it  of    little  value    as   a  prophylactic.     The 


consequences  might  have  been  disastrous  to  the  cause,  had 
not  new  cases  of  vaccinia  been  opportunely  discovered. 

In  April,  1866,  a  case  of  cow-pox  occurred  in  Beaugency, 
France,  which,  by  transmission  through  successive  heifers, 
was  perpetuated  by  the  French  government,  with  the  aid 
of  the  French  Academy  of  Medicine.  Four  years  later,  in 
1870,  this  stock  was  brought  to  America  by  Dr.  Henry  A. 
Martin,  of  Boston. 

Among  dairy  herds  in  this  country,  the  development  of 
an  occasional  case  of  vaccinia  is  not  rare  at  the  present 
time  and  has  not  been  for  the  last  fifteen  or  twenty  years. 
The  prevalence  of  this  disease  has  become  more  noticeable 
in  later  years  on  account  of  infection  from  the  mature 
heifers  and  milch  cows  frequently  vaccinated  by  propa- 
gators. There  is  great  difficulty  in  preventing  the  spread- 
ing of  cow-pox  among  unvaccinated  animals  that  come  in 
contact  with  the  vaccinated.  Were  it  not  for  the  most 
scrupulous  care  on  the  part  of  the  vaccinators,  a  large 
proportion  of  animals  would  leave  the  operating  rooms 
with  well-developed  pustules  upon  their  udders,  thus 
furnishing  a  ready  means  of  infecting,  through  the  medium 
of  the  milkers'  hands,  the  various  herds  among  which  they 
may  be  distributed. 

Many  propagators  have  announced  the  discovery  of 
entirely  new  stocks  of  lymph  purporting  to  be  from  spon- 
taneous cases.  The  spontaneous  nature  of  cow-pox  is 
doubted  by  the  best  observers  and  writers  of  the  present 
day,  therefore,  it  remains  an  open  question  whether  all 
these  so-called  spontaneous  cases  did  not  originate  from 
infected  animals  sent  out  from  the  operating  rooms  of 
propagators.  Taking  this  view  of  the  subject,  it  becomes 
evident  that  the  only  existing  stock  of  lymph  now  in  use 


32 

in  this  country  is,  by  hereditary  descent,  still  the  Beau- 
gency,  which  was  imported  in  1870.  Suffice  it  to  say, 
experience  in  all  recent  epidemics  of  small-pox  has  proved 
the  efficacy  of  this  stock  as  a  prophylactic,  as  no  case  of 
variola  following  a  recent  vaccination  or  re-vaccination  has 
been  reported  for  several  j^ears. 

The  discoveries  of  Jenner,  his  experiments,  the  use  of 
the  S(? -called  Jennerian  lymph  for  a  period  of  nearly 
seventy  years,  the  development  of  the  Beaugency  stock 
and  its  important  service  in  the  epidemics  of  the  past 
twenty-seven  years,  are  familiar  to  all  practitioners  of 
medicine. 

That  vaccination  is  the  only  preventive  of  small-pox, 
very  few  at  this  time  doubt. 

That  small-pox  may,  as  an  exception  to  the  rule,  attack 
a  well  vaccinated  person,  all  must  admit ;  for  it  is  a  matter 
of  medical  history,  often  repeated,  that  small-pox  may 
attack  a  person  twice  and  sometimes  thrice.  Many 
eminent  observers,  before  and  since  the  discovery  of 
vaccination,  have  noted  recurrent  cases  of  small-pox. 
Jenner  alludes  to  the  death  of  Louis  XV.  from  a  second 
attack  of  the  disease. 

An  interesting  case  was  observed  in  the  small-pox 
hospital  in  Boston  in  1875.  A  patient,  who,  while  conva- 
lescing, was  temporarily  filling  the  position  of  nurse, 
became  a  victim  a  second  time,  and  proceeded  regularly 
through  the  disease,  all  the  stages  being  just  as  severe 
as  at  first.  On  recovering,  he  was  again  exposed,  and 
contracted  the  disease,  making  a  series  of  three  attacks  in 
the  course  of  eight  months. 

A  similar  case  is  noted  as  having  occurred  in  a  small- 
pox hospital  in  San  Francisco  in  1S76. 


33 


These,  and  many  other  cases,  lead  to  the  conclusion 
that  small-pox  occurs  after  vaccination  no  more  frequently 
than  the  disease  is  repeated  in  the  same  individual.  It 
should  be  remembered,  however,  that  at  the  present  time 
the  opportunities  for  observing  instances  of  small-pox 
following  vaccination  are  greater,  for  the  reason  that  a 
large  proportion  of  the  population  have  been  vaccinated, 
while  but  a  limited  number  have  had  small-pox. 

There  exists  in  the  system  of  all  persons,  to  a  greater 
or  less  degree,  an  undefined  element-principle,  which  may 
be  called  pabulum,  upon  which  the  disease  germ  of  small- 
pox subsists.  All  the  protection  known  to  science  consists 
in  the  destruction  and  elimination  of  this  pabulum.  The 
vaccine  germ,  as  well  as  the  germ  of  variola,  subsists  upon 
this  and  consumes  it.  It  is  evident  that  in  many  persons 
pabulum  is  slowly  reproduced,  in  others,  rapidly.  The 
primary,  infantile  vaccination  of  some  individuals  con- 
tinues to  protect  them  through  life.  This  seems  peculiar 
to  whole  families,  while  others  respond,  in  some  degree,  to 
vaccinia  or  variola,  as  frequently  as  once  in  ten  years. 
Such  persons  should  be  vaccinated  at  least  every  five 
years. 

GROWTH   OF  THE  VACCINE  VESICLE. 

In  primary  vaccinations,  running  a  normal  course,  a 
slight  papular  elevation  will  be  observed  about  the  third 
day  after  the  insertion  of  the  vaccine  lymph.  In  excep- 
tional cases  it  may  be  seen  on  the  evening  of  the  second 
day.  On  the  fourth  or  fifth,  and,  in  rare  cases,  the  sixth 
day,  it  becomes  a  distinct  vesicle  of  a  pearly  color,  with 
edges    a   little   elevated,   and    by    the   eighth    day    it    has 


34 

attained  its  height  and  is  filled  with  clear  lymph,  its 
elevated  margin  and  depressed  centre  being  more  marked. 
About  this  time  the  commencement  of  umbilication,  due 
to  the  drying  of  the  lymph  contained  in  the  central  cells, 
is  observed.  The  areola,  or  pink  circle  around  the  vesicle, 
begins  to  be  more  prominent  and  continues  to  extend  for 
two  or  three  days,  being  attended  by  more  or  less  indura- 
tion and  swelling  of  the  axillary  glands.  When  the 
areola  is  at  its  height,  the  constitutional  symptoms,  fever, 
headache  and  backache,  are  more  or  less  severe.  After 
the  tenth  day,  the  areola  begins  to  fade,  and  by  the  four- 
teenth, a  hard,  brown  scab  has  formed,  w^hich,  if  left  to 
mature,  falls  from  the  twentieth  to  the  twenty-seventh  day, 
leaving,  in  many  cases,  a  depressed,  foveolated  scar, 
having  small  pits,  or  apparent  pin-holes,  in  its  centre. 
The  pitted  scar  does  not  always  exist.  The  areola  and 
constitutional  symptoms  are  the  only  sure  conditions 
warranting  a  favorable  decision.  This  is  the  usual  course 
of  a  normal  vaccination.  Should,  however,  the  action  of 
the  lymph  be  delayed  even  until  the  eighth  day,  before 
any  sign  of  vesication  takes  place,  and  then  go  regularly 
through  its  course,  it  does  not  change  the  protective  nature 
of  the  vaccination.  Many  deviations  from  the  normal 
course  of  the  vaccine  disease  may  occur. 

It  is  well  to  note-  that  secondary  vaccinations  seldom 
run  a  uniform  course  of  development.  The  stages  are 
usually  of  shorter  duration.  Local  irritation  often  com- 
mences within  twenty-four  hours  after  the  initial  operation, 
the  subject  feels  ill  at  this  early  date,  and  by  the  fifth  day 
the  topical  inflammation  and  constitutional  sj^mptoms  have 
entirely  disappeared.  The  same  variation  will  be  noticed 
in    varioloid,    as    distinguished    from    variola,    the    former 


35 

running  through  its  entire  course,  to  the  falling  of  the 
crusts,  in  half  the  time  required  for  the  latter. 

It  is  not  unusual  for  the  areola  accompanying  a  vacci- 
nation to  extend  far  below  the  elbow  and  even  to  the  wrist, 
giving  rise  to  the  often  reported  instances  of  erysipelas. 
Many  of  the  older  vaccinators  called  this  erysipelas,  but 
according  to  later  observations,  the  constitutional  symp- 
toms of  that  disease,  such  as  rigors,  rapid  pulse  and  high 
temperature,  are  not  found  present.  Therefore,  the 
conclusion  that  the  case  is  simply  intensified  areola  and 
nothing  more  should  be  formed. 

True  erysipelas  will,  in  a  certain  very  small  proportion 
of  cases,  follow  vaccination,  regardless  of  the  purity  of  the 
lymph  used,  or  the  care  the  surgeon  may  have  taken  in 
applying  it.  The  history  of  vaccination  has  always 
furnished  reports  of  such  cases.  If  this  complication 
arises  within  twenty-four  hours  from  the  time  the  lymph 
is  inserted,  it  may  reasonably  be  attributed  to  septic 
germs  introduced  into  the  circulation  with  the  lymph ;  if 
later  in  the  course  of  development,  it  must  be  attributed 
to  atmospheric  germs  entering  after  the  vaccination. 

Vaccine  roseola  and  lichen  are  so  often  seen  in  the 
practice  of  all  physicians  that  it  is  unnecessary  to  describe 
them. 

Vaccine  exanthema,  or  general  eruption,  is  either 
erythematous,  lichenoid,  or  vesicular  in  form,  and  is 
recognized  by  all  experienced  vaccinators,  but  it  has  often 
puzzled  young  physicians,  and  caused  apprehensions  of 
approaching  variola,  blood-poisoning,  or  other  frightful 
results  of  the  use  of  vaccine  virus,  described  in  newspapers 
by  the  opponents  of  vaccination. 

These     erythematous    eruptions,    which   are    likely    to 


VACCINE   ROSEOLA. 

Appearing  on  the  ninth,  tenth  or  eleventh  day  after  vaccination. 


VACCINE  ERYTHEMA  OR  DISTRIBUTED  AREOLA. 

Appearing:  on  the  eleventh  day  after  vaccination  and  disappearing  on  the  thirteenth. 


38 

appear  on,  or  about,  the  ninth,  tenth,  or  eleventh  day,  and 
continue  from  two  to  three  days,  may  be  called  distributed 
areolae,  and  should  be  classed  with  the  general  constitu- 
tional sj-mptoms  of  the  vaccine  disease.  When  the  areola 
is  extensive  and  at  its  height,  it  becomes,  by  reason  of  its 
intensit}^,  diffused  or  distributed  over  a  portion  of  the 
cutaneous  surface,  or  over  the  entire  body.  This  erythema 
always  subsides  gradually,  together  with  the  local  areola. 
It  may  attend  the  normal  course  of  the  vaccine  disease. 

Another  apparent  deviation  in  the  course  of  the  vaccine 
vesicle  is  often  seen  in  cases  of  intense  inflammation, 
resulting  in  ulceration,  man}-  times  indolent  and  slow  in 
healing. 

This  condition  is,  no  doubt,  governed  largely  by  the 
extent  of  the  cutaneous  surface  upon  which  the  vaccine 
lymph  is  applied.  An  extended,  broad  pustule  is  always 
attended  with  more  or  less  topical  inflammation,  which,  in 
many  cases,  leads  to  sloughing.  When  the  Ij^mph  used  is 
plentifully^  supplied  wdth  vaccine  germs,  in  other  words^ 
when  it  is  very  active,  it  will  invariably'  produce  a  confluent 
vesicle,  W'hich  may  naturally  be  attended  with  intense 
inflammation  and  increased  local  temperature,  sometimes 
resulting  in  a  destruction  of  the  surrounding  tissues.  The 
same  condition  follows,  in  many  cases,  a  confluent  patch 
of  variolous  eruption.  It  readily  j'ields  to  mild,  stimulat- 
ing, local  treatment,  with  due  attention  to  cleanliness. 

It  is  the  large,  confluent  vesicle  which  alwaj'S  leaves  a 
large,  deep,  shining  scar,  with  none  of  the  characteristic 
indentations  or  pits  so  commonly  mentioned  as  proof  of  a 
perfect  cicatrix.  It  is  not  conclusive  that  the  smooth,  deep, 
shining  scar  may  not,  and  does  not  frequently  exist  after 
a  good  and  protective  vaccination.     The  vaccinator  would 


39 

not  be  warranted  in  pronouncing  sucli  a  patient  unpro- 
tected; for  it  is  certain  that  the  areola  and  constitutional 
symptoms  afford  the  only  positive  evidence  of  perfect 
protection. 

Re-vaccination  of  all  such  cases  readil^^  proves  that 
they  are  protected. 

It  appears,  by  the  recent  writings  of  some  authors,  that 
all  these  deviations  must  be  due  entirely  to  the  character 
of  the  Ij^-mph  introduced,  but,  the  works  of  older  vaccina- 
tors show  that  at  no  time  in  the  history  of  the  practice  of 
vaccination  has  the  surgeon  escaped  these  occasional 
results.  Such  developments  will  occur  as  exceptions  to 
the  rule.  Injury  to  the  maturing  pustule,  personal  idio- 
syncrasies of  the  patient,  and,  without  doubt,  the  use  of 
virus  prolific  in  vaccine  germs,  applied  over  too  extensive 
a  surface,  are  among  the  common  causes  of  degenerating 
vesicles. 

Many  cases  of  suppurating,  slowly  healing  ulcers  are 
due  wholly  to  an  injury  to  the  vaccine  vesicle  in  the  course 
of  its  development.  The  removal,  by  accident  or  otherwise, 
of  any  portion  of  the  capsule,  or  crust,  allows  the  injured 
surface  to  become  infected  by  the  entrance  of  atmospheric 
germs. 

Much  has  been  said  and  written  concerning  a  certain 
peculiar,  eccentric  action  of  animal  lymph,  described  as 
"raspberry  mark,"  or  "excrescence,"  "red  papule,"  "nanee- 
vus,"  etc.  This  is  not  a  result  known  to  modern  vaccina- 
tors alone,  nor  existing  only  in  cases  where  animal  U'mph 
has  been  used,  as  it  was  well  known  to  the  earlier  vac- 
cinators, and  followed  the  use  of  humanized  as  well  as 
bovine  vaccine  virus.  It  Avas  often  observed  during  the 
extensive    vaccinations    of    1872-3.     It     seems    to    be    an 


VACCINE  VESICLES.    Tenth  Day. 

Exact  size  of  original  scarifications  shown,  to  illustrate  tiiat  tiie  extent  of  the  scarified 

surface  governs  the  size  of  vaccine  vesicles.     Both  vesicles  produced 

with  the  same  lymph. 


% 


m  i 


TYPICAL   VACCINE   VESICLES. 
Tenth  Day. 


42 

exuberant  granulation  of  the  nature  of  Keloid,  stimulated, 
no  doubt,  by  the  application  of  serous  fluid  to  the  corium. 
It  is  needless  to  say  that  serum  does  not  possess  vaccine 
germs  in  an  active  condition,  therefore,  the  results  are 
irregular  and  unprotective. 

That  septic  matter  may  obtain  admission  into  vaccine 
lymph,  prepared  without  aseptic  precautions,  is  not  ques- 
tioned, but  the  cases  of  so-called  septicaemia,  which 
commence  late  in  the  course  of  the  vaccine  disease,  and 
are  sometimes  reported  as  the  result  of  septic  matter  exist- 
ing in  the  lymph  before  it  is  introduced  into  the  system, 
are  from  infected  vesicles,  acquiring  the  infection  from 
atmospheric  organisms,  which  have  found  their  way  into 
the  pustule  during  its  incubating  period.  In  such  cases, 
were  the  sepsis  introduced  with  the  lymph,  septicaemia, 
with  its  usual  train  of  symptoms,  rigors,  high  temperature, 
gland  infection,  or  erysipelas  at  the  point  of  the  local 
wound,  would  develop  within  a  few  hours. 

A  very  rare,  and,  to  the  physician,  interesting,  case  of 
eccentric  action  of  animal  vaccine  virus  occurred  in  a  ward 
in  Boston  in  1882,  and  since  no  parallel  case  can  be  found 
in  any  ancient  or  modern  writings  on  this  subject,  it  seems 
to  be  of  suf&cient  importance  to  merit  description. 

The  following,  from  the  pen  of  Dr.  J.  H.  McCollom, 
appeared  in  the  Boston  Medical  and  Surgical  Journal  of 
October  12,  1882. 

"The  case  about  to  be  reported  is  entirely  unique;  the 
record  of  a  similar  one  I  have  been  unable  to  find  any- 
where. Mrs.  B.,  a  healthy  woman,  the  mother  of  two  chil- 
dren, was  vaccinated  February  13th,  with  bovine  virus,  by 
her  family  physician,  Dr.  Harris,  of  Roxbury,  through 
whose  kindness  I  saw  the  case,  and  to  whom  I  am  indebted 


GENERAL  VACCINIA. 

Contracted  through  the  medium  of  the  mother's  milk. 


44 

for  the  following  notes.  On  the  fifth  day  after  vaccination 
the  patient  complained  of  headache,  was  feverish,  and  in 
fact  had  the  usual  amount  of  discomfort  that  attends  a 
successful  re -vaccination,  Mrs.  B.  was  at  this  time 
nursing  her  infant,  a  child  about  six  months  old.  The 
child  had  not  been  vaccinated  on  account  of  eczema  from 
which  it  was  suffering  at  that  time.  On  March  9th,  as 
nearly  as  the  mother  can  remember,  an  eruption  appeared 
on  the  head,  thorax,  and  the  legs  of  the  child,  who  had 
been  feverish  and  irritable  for  two  or  three  days  previous. 
On  some  portions  of  the  body  the  eruption  w^as  confluent, 
but  on  the  arms  and  thighs  it  presented  the  characteristic 
appearance  of  cow-pox.  It  was  not  an  instance  of  acci- 
dental inoculation,  for  there  was  no  possible  way  by  which 
the  child  could  have  introduced  the  virus  at  so  many 
different  points.  The  disease  must  have  been  contracted 
from  the  mother  through  the  medium  of  her  milk.  The 
child  was  not  very  sick,  although  there  was  considerable 
discomfort  from  the  eruption.  The  drawing  gives  a 
remarkabl}^  good  idea  of  its  appearance.  In  order  to  test 
the  matter  more  thoroughly.  Dr.  Cutler,  of  Chelsea,  charged 
a  few  points  with  the  lymph,  and  inoculated  a  cow  on  the 
vulva.  On  March  15th,  I  received  a  note  from  him  in 
which  he  sa3^s,  'I  send  you  points  taken  to-day  from  a 
perfect  vesicle  planted  upon  the  vulva  of  an  animal  seven 
days  ago.  The  vesicle  has  an  elevated  base,  a  smooth, 
regular,  perfectly  spherical  margin,  is  not  yet  umbilicated, 
and  has  all  the  characteristics  of  a  pustule  resulting  from 
a  series  of  human  transmissions.  This  puts  bej^ond  cavil 
the  question  of  identity  in  the  Roxbury  case.' "  The  final 
proof  of  the  accuracy  of  the  diagnosis,  namely,  vaccinat- 
ing a  human  being  with  this  virus,  was  not  attempted. 


45 

COURSE   TO    BE     TAKEN   BY   PHYSICIANS 
WHEN   VARIOLA  IS   DISCOVERED. 

The  following  extract  from  Seaton's  Handbook  of 
Vaccination  treats  tlie  subject  in  a  forcible  and  lucid 
manner. 

"No  question  in  medical  practice  may  be  regarded  as 
more  completely  settled  than  the  course  which  a  practi- 
tioner should  take  when  there  are  persons  of  any  age 
whatever,  unvaccinated  or  not  otherwise  protected  against 
small-pox,  in  a  house  or  family  in  which  that  disease 
breaks  out.  At  once,  and  without  any  dela}-,  the  vaccina- 
tion of  all  such  persons  should  be  performed;  the  loss  of  a 
day  may  be  the  sacrifice  of  a  life.  It  does  not  follow  that 
because  a  person  has  been  exposed  to  the  infection  of 
small-pox  that  he  has,  therefore,  received  the  infection,  and 
the  vaccination  may  be  in  time  to  prevent  the  disease 
altogether;  but  supposing  that  before  the  vaccination  is 
performed,  the  variolous  infection  has  actuall}^  been  taken 
up  by  the  system  (of  which,  of  course,  during  the  stage  of 
incubation  we  can  know  nothing ) ,  unless  that  infection  have 
so  far  got  the  start  that  the  small-pox  symptoms  appear 
before  the  vaccination  reaches  the  stage  of  developed 
areola,  the  vaccine  process  will  either  prevent  or  modify 
the  small-pox  eruption;  if,  on  the  other  hand,  the  variola 
manifests  itself  before  the  vaccination  has  reached  its 
protective  stage,  its  stage  of  areola,  the  vaccination, 
though  it  will  have  done  no  good,  will  most  certainly  have 
done  no  harm — the  small-pox  will  simply  go  on  as  though 
it  had  never  been  performed.  Now,  whether  the  vaccina- 
tion shall  reach  the  stag^e  of  areola  or  not  before  the  small- 
pox  appears,  depends  entirely  on  the  length  of  time  which 


46 

Tiad  elapsed  between  the  reception,  by  the  system,  of  the 
^•ariolous  poison  and  the  performance  of  the  vaccination. 
As  the  incubative  period  of  small-pox  is  twelve  days,  while 
the  time  requisite  to  bring  vaccination  to  the  stage  of 
areola  is  only  nine  da3'S,  vaccination  performed  any  time 
within  the  first  three  days  will  reach  areola  soon  enough 
to  produce  its  protective  power ;  after  this,  whatever  the 
local  success  of  the  vaccination,  no  constitutional  protec- 
tion will  be  imparted. 

"If  there  were  only  any  means  of  ascertaining  whether 
a  person  exposed  to  small-pox  infection  had  actually 
received  it,  and,  if  so,  at  what  moment  this  had  taken 
place,  we  should  know  exactly  whether  it  were  worth  while 
to  vaccinate  or  not;  but  as  no  such  means  exist,  the 
obvious  rule  of  practice  is  to  assume  that  the  poison  has 
not  been  inhaled,  or  has  only  recently  been  inhaled,  and  to 
give  our  patient  the  chance.  But  no  prudent  practitioner, 
vaccinating  under  these  circumstances,  will  commit  him- 
self as  to  the  protective  value  of  his  vaccination  until  he 
has  seen  the  areola  completely  formed. 

"For  want  of  knowledge  or  of  consideration  of  these 
simple  facts,  practitioners  have  repeatedly  compromised 
their  credit,  many  lives  have  been  lost  that  should  have 
been  saved,  and  erroneous  entries  are  daily  made  in  our 
death-registers.  Seeing  perfect  vaccine  vesicles  on  the 
eighth  day,  the  practitioner  who  was  not  aware  of  the 
necessity  of  waiting  for  areola  has  promised  safety,  and 
heen  cruelly  disappointed;  his  credit  and  the  credit  of 
vaccination  have  equally  suffered.  The  occurrence  of 
three  or  four  cases  together  of  unmodified,  and  perhaps 
fatal,  small-pox  in  persons  having  well-formed  and  com- 
plete vaccine  vesicles  on  their  arms,  has  at  times  led  the 


47 


practitioner,  not  to  the  true  explanation,  viz.,  that  his 
vaccination  in  these  cases  has  been  too  late,  but  to  the 
notion  that  vaccination  was  always  useless  when  small-pox 
was  incubating,  and  even  to  the  absurd  and  totally 
unfounded  supposition  that  it  might  increase  the  danger ; 
so  he  has  shut  up  his  vaccine  lancet,  and  children  have 
been  allowed  to  perish  from  non-performance  of  vaccina- 
tion, whose  deaths  were  clearly  chargeable  to  his  error. 
Our  death-registers  contain  innumerable  entries  of  deaths 
from  'small-pox  after  vaccination,'  which  were  simply  cases 
of  death  from  small-pox  in  children  in  whom  vaccination 
was  performed  during  the  incubation  of  small-pox;  and 
heaps  of  published  and  other  records  are  quite  unusable 
for  any  statistical  purposes,  because  cases  of  this  kind  are 
not  distinguished  from  the  cases  in  which  sma^.-pox  really 
did  occur  in  persons  who  had  properly  received  the  consti- 
tutional infection  of  vaccination. 

"The  practice,  which  I  have  known  at  times  adopted, 
of  vaccinating  a  person  after  symptoms  of  small-pox  have 
actually  manifested  themselves,  is  utterly  absurd ;  so  far 
as  the  patient  is  concerned,  the  effect,  of  course,  is  7iil-,  but 
on  account  of  the  discredit  it  tends  to  bring  upon  vaccina- 
tion with  the  public,  it  is  a  practice  which  should  be 
strongly  discountenanced." 

CULTIVATION  OF  VACCINE  VIRUS. 

Animal  vaccination  has  been  successfully  practised  in 
the  United  States  for  more  than  twenty  years,  and  experi- 
ence has  proved  it  to  be  the  only  method  by  which  a  large 
supply  of  vaccine  lymph,  equal  to  the  demands  of  a  general 
epidemic   of   small-pox,    can    be    furnished.     During    this 


48 

period,  nearl}^  all  the  methods  of  vaccinating  animals,  and 
collecting  and  storing  vaccine  h'mph,  now  practised  in  the 
older  countries,  have  been  thoroughh^  tested,  and  finally 
abandoned  in  this  country,  until  now  the  pure  h^mph  taken 
from  thoroughly  cleansed,  open  vesicles,  and  stored  by 
dr^nng  upon  ivory  points,  is  admitted  to  be  the  safest, 
most  reliable  and  convenient  form. 

The  technique  of  bovine  vaccination  b}^  different  opera- 
tors varies  to  such  an  extent,  in  so  many  essential  features, 
that  space  will  not  admit  of  descriptions  in  detail.  There 
is  a  wide  difference  of  opinions  as  to  the  age  of  animals 
best  adapted  for  the  cultivation  of  vaccine  h^mph,  some 
propagators  choosing  nursing  calves,  others  3'earlings,  and 
many,  mature  young  heifers,  preferabl}^  from  two  to  four 
3^ears  old.  Ideas  also  vary  as  to  the  proper  period  for 
opening  the  vaccine  vesicles.  It  is  certain,  however,  that, 
in  most  cases,  the  pustules  yield  a  much  larger  quantity 
of  Ij^mph  after  one  hundred  and  sixtj^-eight  hours  of 
incubation  than  when  opened  earlier  in  the  course  of  devel- 
opment. It  ma}^  be  claimed,  perhaps  with  some  degree  of 
reason,  that  h'mph  taken  twenty-four  hours  earlier  will 
give  better  results  and  a  much  larger  percentage  of 
successful  vaccinations,  in  which  case  one  hundred, 
and  fort3^-four  hours  should  constitute  the  incubating 
period. 

An  operating  room  for  the  propagation  of  vaccine  virus 
should  be  arranged,  as  far  as  possible,  with  a  view  to 
complete  asepsis.  The  same  maj^  be  said  of  the  stables  in 
which  the  animals  are  kept  during  the  incubating  period. 
All  floors,  ceilings  and  walls  should  be  made  of  non-absorp- 
tive materials,  so  constructed  as  to  admit  thorough  flushings 
of  boiling  water  and  antiseptic   solutions.     All   forms   of 


c 

a, 

g 
o 


C3 

c 

m 


a 
O 


50 

beddiiig  for  the  animals  should  be  regarded  as  vehicles  for 
the  lodgement  and  cultivation  of  microbes. 

Asepsis  in  the  cultivation  of  vaccine  lymph  must  be 
applied  to  the  surroundings  of  the  animals  during  the 
incubating  stage  of  the  pustules  and  in  the  operating 
rooms,  where  the  lymph  is  extracted  from  the  vesicles  and 
stored.  The  product  of  the  vesicles,  after  it  is  taken  from 
the  animals,  if  not  aseptic,  cannot  be  sterilized  nor  purified 
by  any  antiseptic  agent,  without  destroying  also  the  life  of 
the  active  principal  of  the  lymph.  All  forms  of  vaccine 
virus,  except  the  pure  exuding  lymph,  should  be  classed 
as  possibly  infected  matter,  having  remained  on  the  animal 
for  a  full  week,  meanwhile  accumulating  dust  from  the 
stable  and  atmospheric  germs.  Dried  lymph  in  the  form  of 
crust  has  generally  passed  out  of  use  in  this  country.  The 
quantity  of  this  crust  which  exists  on  vaccinated  animals  is 
very  tempting  to  propagators.  It  enters  very  largely  into 
the  glycerine  pastes  and  vaccinating  fluids  stored  in  glass 
tubes,  and  issued  in  France,  Italy  and  Germany  under 
the  name  of  aseptic,  sterilized  vaccine  virus.  The  operators 
lay  great  stress  upon  the  sterilization  of  all  vehicles  in 
which  the  lymph  is  stored,  but  the  fact  remains  that  this 
product  is  that  portion  of  the  vesicle,  formed  from  the 
debris  of  broken-down  tissue,  cell  detritus  and  an  admix- 
ture of  pus,  which  has  not  been  and  cannot  be  sterilized. 

METHODS   OF   VACCINATING. 

Cleanliness  of  the  cutaneous  surface  upon  which  the 
vaccine  virus  is  applied  and  of  the  instruments  employed 
in,  making  the  necessary  scarifications  is  of  the  utmost 
importance. 


>> 

c 

a 

E 

o 
o 


> 
c 

C3 
Ml 

e 
z 


The  vaccinator  should  always  avoid  all  forms  of  vacci- 
nating instruments,  or  any  instrument  which  is  designed 
for  successive  cases.  A  common  sewing  needle  is  a  con- 
venient scarifier  used  by  many  operators,  one  for  each 
subject.  When  once  used,  it  is  throAvn  aside,  and  a  new 
one  applied  to  the  next  in  order.  Physicians  who  use 
lymph  stored  upon  ivory  lancet  points  will  find  nothing  so 
clean  and  convenient  for  the  purpose  of  scarifying  as^he 
ivory  point,  and  it  has  the  advantage  of  always  being  at 
hand.     It  should  not  be  applied  to  more  than  one  person. 

The  scarification  should  be  on  the  left  arm  at  a  point 
near  the  insertion  of  the  deltoid  muscle,  and  should  be 
just  deep  enough  to  bring  into  view  the  fine  net-work  of 
capillary  vessels.  A  little  bleeding  is  of  no  consequence, 
an  excess  should  be  avoided. 

The  too  common  practice  of  vaccinating  the  lower  limbs 
should  be  avoided.  Vaccinations  upon  the  leg  below  the 
knee  have  often  produced  serious  results.  The  constant 
movement  of  the  muscles  in  locomotion  and  the  irritation 
from  the  clothing  serve  to  inflame  the  maturing  vesicle. 
The  oedema  which  often  attends  a  vaccination  on  the  leg 
obstructs  the  venous  circulation  and  favors  slow  healing 
and  indolent  ulceration,  especially  if  the  subject  has  passed 
middle  life.  In  such  cases,  similar  unfavorable  results 
may  follow  simple  abrasions  of  the  skin  or  any  slight 
injury. 

Many  vaccinators  cover  the  scarification  and  its  applied 
lymph  with  surgeon's  plaster,  but  this  should  not  be 
countenanced,  as  it  confines  the  secretions  and  favors 
septic  formations. 

All  careful  physicians  require  their  vaccinated  patients 
to  return  for  inspection  and   advice  on  the  fifth  or  sixth 


> 

T3 
C 
s« 

Ml 

C 


54 

day.  Dressings,  like  poultices,  oil,  tallow,  vaseline,  or 
water,  tending  to  soften  the  capsule  of  the  pustule,  should 
never  be  applied  to  an  unbroken  vesicle.  Every  application 
or  treatment  which  may  deprive  the  vesicle  of  its  natural 
protection,  the  scab,  serves  only  to  prolong  the  healing 
processes  and  furnishes  a  free  entrance  to  microorganisms. 
If,  by  accident  or  suppuration,  the  crust  or  capsule  has 
been  sacrificed,  then  the  surgeon  is  warranted  in  the  use 
of  any  remedy  which  his  judgment  dictates. 

AGE   FOR  VACCINATING. 

The  vaccine  disease  is  well  borne  by  ver}"  young 
infants  prior  to  dentition.  The  preferable  age  is  from  one 
to  two  months. 

This  age  was  usuall}-  selected  bj^  the  older  vaccinators, 
for  the  reason  that  the  vaccine  disease  appears  more  violent 
in  proportion  to  the  increased  age  of  the  child. 

Physicians  would  follow  the  right  course  now,  should 
they  vaccinate  all  infants  before  making  their  last  visits 
to  convalescent  mothers. 

There  is  a  growing  tendency-,  on  the  part  of  physicians 
as  well  as  of  parents,  to  neglect  vaccination  until  compelled 
by  school  regulations. 

RE-VACCINATION. 

The  best  authorities  advise  re-vaccinating  at  puberty. 

On  the  approach  of  an  epidemic,  or  whenever  a  case  of 
small-pox  is  discovered,  re-vaccination  becomes  imperative 
in  that  locality. 


C 


Physicians,  as  a  class,  are  notably  exempt  from  small- 
pox, although  very  often  exposed.  It  is  their  custom  to 
re-vaccinate  themselves  whenever  a  case  of  variola  appears 
in  their  vicinity.  Should  this  be  practised  by  all  persons, 
an  epidemic  of  small-pox  would  be  unknown. 

COMPULSORY   VACCINATION. 

To  a  superficial  investigator,  compulsory  vaccination 
may  appear  to  be  an  infringement  upon  the  personal  rights 
of  an  individual,  but  when  his  relations  to  society  are  such 
that  he  becomes  dangerous  to  the  life  and  health  of  others, 
he  should  then  be  considered  a  nuisance,  and  legally 
treated  as  such.  A  law  which  compels  vaccination  reaches 
beyond  the  personal  question,  and  affects  the  interests  of 
the  community,  for  every  unvaccinated  person  contributes 
to  the  material  that  increases  great  epidemics.  No  city 
with  a  large  unvaccinated  population  is  ever  safe  from  the 
ravages  of  small-pox. 

Dr.  Carpenter,  whose  efforts  in  behalf  of  the  hygienic 
good  of  man  have  been  both  earnest  and  successful,  was  a 
zealous  advocate  of  compulsory  vaccination.  He  main- 
tained that  it  is  the  right  and  the  duty  of  the  State  to  act 
for  the  good  of  the  public  in  matters  of  health  as  well  as 
of  education ;  that  society  should  be  protected  against 
disease  and  death  as  well  as  against  illiteracy. 

The  ef&cacy  of  vaccination  as  a  preventive  of  small- 
pox is  doubted  by  no  unprejudiced  person.  Small-pox  will 
never  be  blotted  out  of  the  list  of  existing  diseases  until 
the  practice  of  vaccination  and  re-vaccination  is  extended 
and  enforced. 


^ii ^ y V 


INDEX   TO   ILLUSTRATIONS. 


Bust  of  Edward  Jenner,  frontispiece. 

Varicella,  third  daj^     .              .              .              .              .              .              12 

Variola,  third  da^^ 

13 

"         fourth  day, 

15 

,    "         fifth  day, 

17 

"         sixth  day, 

19 

seventh  day, 

21 

"         eighth  day, 

23 

' '         tenth  day, 

25 

i    "         eleventh  day, 

26 

"                "           "     actual  size, 

27 

Vaccine  Roseola, 

36 

"        Erj'thema, 

37 

Vesicles,  tenth  daj', 

40 

Typical, 

41 

General  Vaccinia, 

43 

Operating  Room, 

49 

Section  of  Stable, 

51 

Office  Interior, 

53 
55 

Caricature  by  Gillray  . 

57 

INDEX. 


Histor}'  of  Variola,        .... 

Inoculated  Variola,       .  .  .  . 

Measles,  ..... 

Variola  and  Varicella.      Comparative  Description, 

Vaccinia,  ..... 

Growth  of  the  Vaccine  Vesicle, 

Vaccine  Roseola,  .... 

Vaccine  Erythema,        .... 

Course  to  be  taken  when  Variola  is  Discovered, 

Cultivation  of  Vaccine  Virus, 

Methods  of  Vaccinating, 

Age  for  Vaccinating, 

Re- Vaccination,  .... 

Compulsory  Vaccination, 


3 
9 

lO 

II 

28 

33 
36 
37 
45 
47 
50 
.54 
54 
56 


COLUMBIA  UNIVERSITY  LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 


DATE  BORROWED 

DATE  DUE 

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DATE  DUE 

^!%      .  i^  "0 

:..-■. 

C28(l  I  40)  Ml  00 

RC183 


N44 


New  England  vaccine  company. 


m^3)0:  l^Ju>ua 


